Clinical Guideline - VCU Medical Center

[Pages:11]Clinical Guideline

! This guideline should not replace clinical judgment.

Peripheral IV Extravasation/Infiltration (PIVIE) Treatment

Inpatient and Outpatient Pediatrics

NONCYTOTOXIC INFILTRATIONS & EXTRAVASATIONS: GUIDELINE FOR PEDIATRIC PATIENTS

Purpose: To describe the management of intravenous (IV) infiltrations and extravasations in pediatric patients.

Applicability: Prescribers, Pharmacists, Nurses

Procedure: 1. Definitions

a. Infiltration: the inadvertent administration or leakage of a non- vesicant (e.g., irritant) medication or solution into the surrounding tissue instead of into the intended vascular space. This occurs when the catheter becomes dislodged or the vein ruptures, causing fluid to leak into the surrounding tissue.

b. Extravasation: the inadvertent administration or leakage of a vesicant medication or solution into the surrounding tissue instead of into the intended vascular space. A vesicant is a solution or medication that causes the formation of blisters with subsequent sloughing of tissues occurring from tissue necrosis.

Note: Phlebitis is an inflammation of the intima of the vein, and is a commonly reported complication of infusion therapy. It is completely different from, but is often confused with infiltration and extravasation. It usually occurs when the vein is irritated from solutions.

2. Signs and Symptoms of IV Infiltrations/Extravasations a. Swelling b. Redness c. Stinging, burning, or pain at the administration site d. Loss of blood return from the IV e. IV flow rate that slows or stops f. Leaking around the IV catheter or implanted port needle g. Skin tightness at the venipuncture site h. Blotching of the skin i. Change in temperature of the skin, cool or warm

3. Measurement Based Assessment Tool a. The Cincinnati Pediatric Intravenous Extravasation Assessment System standardizes the identification and assessment in the early stage of infiltration and extravasation, thus reducing the need for treatment and serious complications. b. Three steps in the coding system: i. Volume measurement: measure max dimension of swelling of affected area (X), measure the ARM length (Y), calculate (X/Y) x 100= %. See Figure 1. ii. Medication Identification: Red (high risk), Yellow (intermediate risk), Green (low risk). See Figure 2. iii. Documentation: Document immediately in Cerner.

For questions concerning this guideline, contact: chorclinicalguidelines@



First approved: November 2021 Next expected update: November 2024

Clinical Guideline

! This guideline should not replace clinical judgment.

Peripheral IV Extravasation/Infiltration (PIVIE) Treatment

Inpatient and Outpatient Pediatrics

Figure 1. Cincinnati Children's Hospital Medical Center IV Extravasation System

For questions concerning this guideline, contact: chorclinicalguidelines@



First approved: November 2021 Next expected update: November 2024

Clinical Guideline

! This guideline should not replace clinical judgment.

Peripheral IV Extravasation/Infiltration (PIVIE) Treatment

Inpatient and Outpatient Pediatrics

Figure 2. Venous Infusion Extravasation Risk Chart

For questions concerning this guideline, contact: chorclinicalguidelines@

First approved: November 2021 Next expected update: November 2024

Clinical Guideline

! This guideline should not replace clinical judgment.

Peripheral IV Extravasation/Infiltration (PIVIE) Treatment

Inpatient and Outpatient Pediatrics

4. Management of Noncytotoxic Infiltrations/Extravasations (See Figure 3). a. Stop the infusion b. Assess the affected site for pain, erythema, and size of the infiltration c. Elevate the affected extremity to reduce swelling d. Notify provider of suspected infiltrate i. A provider must evaluate an extravasation. ii. A provider must write orders for compresses and antidotes as appropriate. (Refer to Tables I and II) iii. All treatments, including warm and cool compresses, require a provider order iv. All orders for compresses must include the frequency and duration of application e. Estimate total volume of fluid that escaped into the tissue f. Obtain orders for treatment interventions as needed g. Attempt to aspirate residual drug from the IV needle/catheter using a small (1-3 mL) syringe. If administering antidote, the first dose (see Table I) may be administered into the subcutaneous tissue via this cannula h. If not administering an antidote, remove IV catheter i. Apply cold or warm compresses as ordered (see Table II) i. Do not apply pressure to the site ii. Compresses should never be warmed in the microwave iii. For extravasation in the neonate, defer to the provider for use of compress j. Assess skin surface every hour x 24 hours for induration, discoloration, and feeling of numbness in the affected extremity k. Educate patients/families on worsening symptoms and to notify a provider: i. Increased swelling ii. Increased pain iii. Blistering, ulceration, induration or other skin changes iv. Altered tissue perfusion v. Changes in sensation l. Consider a plastic surgery consult for any of the following: i. Increased swelling ii. Increased pain iii. Blistering, ulceration, induration or other abnormal skin changes iv. Large infiltrate (greater than 25-50 mLs) m. Consider a vascular surgery consult for any of the following: i. Altered tissue perfusion ii. Change in sensation n. Elevate the affected extremity for 48 hours to reduce swelling. After 48 hours, encourage the patient to use the extremity normally to promote full range of motion

For questions concerning this guideline, contact: chorclinicalguidelines@

First approved: November 2021 Next expected update: November 2024

Clinical Guideline

! This guideline should not replace clinical judgment.

Peripheral IV Extravasation/Infiltration (PIVIE) Treatment

Inpatient and Outpatient Pediatrics

Figure 3. Treatment Plan % Swelling and Infusate Component

Extravasation >/= 30% AND Red list infusate Extravasation >/= 30% AND Red list infusate

Extravasation >/= 30% AND Yellow or Green list infusate Extravasation < 30% AND Yellow or Green list infusate Extravasation of any % of a Red list Vasoactive medication (dopamine, epinephrine, and related medications)

Action Treat with Hyaluronidase or appropriate antidote per provider order

Clinical evaluation of the extravasation site by bedside RN, provider, and RRT RN to determine if hyaluronidase or appropriate antidote is clinically indicated. Decision criteria include imminent skin loss, and/or peripheral circulation impairment (compartment syndrome) Clinical evaluation of the extravasation site by bedside RN, provider, and RRT RN to determine if hyaluronidase or appropriate antidote is clinically indicated, but hyaluronidase treatment usually NOT indicated. No treatment indicated

IMMEDIATE consult to provider and RRT RN, if necessary, to determine treatment plan and use of phentolamine or appropriate antidote.

5. Outpatient Instructions Related to IV Infiltrations/Extravasations a. These instructions pertain to infiltrations/extravasations that occur in the outpatient infusion center or if the patient is discharged within 72 hours of an inpatient infiltration/extravasation event b. Provide the following instructions to the patient and/or the patient's family: i. Continue to apply cold or warm compresses as ordered (refer to Table 1). Do not apply pressure to the site. ii. Continue to elevate the affected extremity for 48 hours after the event to reduce swelling. After 48 hours, use the extremity normally to promote full range of motion iii. Monitor the infiltration/extravasation site closely for at least 72 hours after the event. Some sequelae may not manifest for 2-3 weeks after the event. Notify your physician and go to the emergency room to seek immediate medical attention if there is: 1. Increased swelling 2. Increased pain 3. Blistering, ulceration, induration or other skin changes 4. Altered tissue perfusion 5. Changes in sensation c. The provider's office and/or nurse should contact the patient the day after an outpatient infiltration/extravasation event to follow-up on the patient's status

For questions concerning this guideline, contact: chorclinicalguidelines@

First approved: November 2021 Next expected update: November 2024

Clinical Guideline

! This guideline should not replace clinical judgment.

Peripheral IV Extravasation/Infiltration (PIVIE) Treatment

Inpatient and Outpatient Pediatrics

6. Documentation of IV Infiltrations/Extravasations a. All infiltrations and extravasations must be verbally reported to the treating provider and the charge nurse on the inpatient unit. b. All infiltrations and extravasations must be electronically reported in the Safety Intelligence Reporting System. c. All infiltrations/extravasations must be documented in the medical record and include the following information: i. Date and time of infiltration/extravasation ii. Infiltrating/extravasating agent (including concentration and diluent) iii. Estimated volume of infiltration/extravasation iv. IV catheter type v. Location of IV insertion site vi. Description of infiltration/extravasation (including but not limited to the following): 1. Size of the affected area 2. Presence of swelling or redness 3. Report of stinging, burning, or pain at the administration site 4. Presence/absence of blood return 5. Decreased IV flow rate 6. Leaking around IV needle/catheter vii. Name of the provider that was notified and time notified viii. Any interventions (including compresses and antidotes) ix. Any response to interventions x. Patient education d. All site checks performed must be documented.

Table I. Treatment of Extravasation

Non-Pharmacologic Elevation Thermal

Topicals Pharmacologic

Hyaluronidase Injection

Overview of Treatment Modalities for Non-cytotoxic Medications

elevate Warm /cold compress (See Table I) apply x 15 mins QID or continuously on initial injury Warm compress disperses agent via increase circulation like hyaluronidase Cold compress ? limit the spread i.e. localizes the drug bacitracin/ collagenase

NICU Dilution: Withdraw 0.1 ml hyaluronidase 150 unit/ ml & place in 0.9 ml NS for concentration 15 units/ ml.

Administer: 15 units by Injection of 0.2 ml at 5 points around periphery of extravasation site. May repeat in 30-60 mins if no resolution. DO NOT use near active infection or purulence.

Pediatrics Dilute 0.1 mL hyaluronidase 150 unit/mL with 0.9 mL NS for a final concentration of 15 units/ml. Administer as five 0.2 mL injections around the periphery of the extravasation site

May repeat in 30-60 minutes if no resolution

Do NOT use near active infection or purulence

For questions concerning this guideline, contact: chorclinicalguidelines@

First approved: November 2021 Next expected update: November 2024

Clinical Guideline

! This guideline should not replace clinical judgment.

Peripheral IV Extravasation/Infiltration (PIVIE) Treatment

Inpatient and Outpatient Pediatrics

Phentolamine Injection*

Topical Nitroglycerin ointment Apply ONCE if no resolution can follow Every 8 hr x 3 dose

Terbutaline (pediatrics)

WEIGHTS < 1 kg: use 0.1 mg/ml concentration Weight < 5 kg: see NICU recommendations

Inject Total dose 0.05 mg by using 0.1 ml SQ at five points on edge of swelling/blanching can repeat in 60 mins but watch for low BP

WEIGHTS > 1 -2.5 kg: USE 0.1 mg/ml concentration

Weight > 5 kg: USE 0.5mg/ml concentration

Inject Total Dose 0.5mg, by Using 0.2 mL SubQ at five points at the leading edge of swelling/ blanching. Can repeat in 60 minutes. Monitor for low BP

Inject total dose 0.1 mg, by Using 0.2 ml SQ at five points on edge of swelling/blanching can repeat in 60 mins but watch for low BP

Weights 2.5-5 kg: USE 0.5 mg/ml concentration

Inject Total dose 0.25mg, by using 0.1 ml SQ at five points on edge of swelling/blanching can repeat in 60 mins but watch for low BPSome say use on Postnatal age >/= 21 days

Do not use on broken skin

DOSE: 4 mm/kg of ointment MAX of 25 mm ( 1 inch)

Weight < 5 kg: 4 mm/kg (max 25 mm) of ointment apply to affected area. Use Gramfield tape to measure.

Weight > 5 kg: 1 inch apply to affected area

Use Gramfield tape: Order sentences:

Monitor BP every 5 minutes x 15 minutes

Nitroglycerin 2% ointment, 4 mm, (weight 1 kg) ,Apply ONCE

MONITOR BP every 5 min x 15 mins

Nitroglycerin 2% ointment , 8 mm, (weight 2 kg), Apply ONCE

Monitor BP every 5 mins x 15 mins

Nitroglycerin 2% ointment 12 mm, (weight 3kg), Apply once Monitor BP every 5 mins x 15 mins

Nitroglycerin 2% ointment 16mm, (weight 4kg), Apply once Monitor BP every 5 mins x 15 mins

Nitroglycerin 2% ointment 20 mm, (weight 5kg), Apply once Monitor BP every 5 mins x 15 mins

Half-life too long in neonates

Do not use in patients < 2 years of age

Patient's 2 years: Dilute 1 mg of terbutaline in 9 mL of NS to make a final concentration of 0.1 mg/mL. Inject 0.1-0.2 mL SubQ doses at the leading edge of the extravasated site

*Phenolamine: extracted form NeoFax and Lexicomp & dose adjusted from pediatric cardiovascular surgery & dental literature.

For questions concerning this guideline, contact: chorclinicalguidelines@

First approved: November 2021 Next expected update: November 2024

Clinical Guideline

! This guideline should not replace clinical judgment.

Peripheral IV Extravasation/Infiltration (PIVIE) Treatment

Inpatient and Outpatient Pediatrics

Table II. Medications Specific Treatment Modalities * For THERMAL Treatment in the neonate, defer to the provider for use of compress

Drug

Mechanism of injury Antitdote

Acyclovir Ampicillin Amiodarone Amphotericin B Aminophylline Arginine Calcium salts Dantrolene Dextrose 10% W,12.5% Diazepam Digoxin DoBUTamine DOPAmine Doxycycline EPInephrine Esmolol Etomidate Fat Emulsion w/out TPN

pH

Hyaluronidase

Osmolarity

Hyaluronidase

pH unknown

Hyaluronidase Hyaluronidase

osmolality/osmolarity Hyaluronidase

pH /osmolarity

Hyaluronidase

osmolarity

Hyaluronidase

pH

Hyaluronidase

osmolarity

Hyaluronidase

osmolarity

Hyaluronidase

osmolarity

Hyaluronidase

vasoconstriction

Phentolamine

vasoconstriction

Phentolamine

pH

Hyaluronidase

vasoconstriction

Phentolamine

pH

Hyaluronidase

osmolarity

Hyaluronidase

Flush Out with Normal Saline

Primary Thermal Compress* warm warm warm warm warm warm warm warm warm warm warm warm warm warm warm warm warm warm

Other

nitroglycerin ont/terbutaline-ped nitroglycerin ont/terbutaline-ped nitroglycerin ont/terbutaline-ped FLUSH OUT procedure by Martin PH British J of Anaesthesia 1994;72:702.

For questions concerning this guideline, contact: chorclinicalguidelines@

First approved: November 2021 Next expected update: November 2024

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